Provider Demographics
NPI:1407048747
Name:PESTRIDGE, MICHIYO
Entity Type:Individual
Prefix:MRS
First Name:MICHIYO
Middle Name:
Last Name:PESTRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3277 PHILLIPS RD
Mailing Address - Street 2:
Mailing Address - City:MARATHON
Mailing Address - State:NY
Mailing Address - Zip Code:13803-2139
Mailing Address - Country:US
Mailing Address - Phone:607-849-3545
Mailing Address - Fax:
Practice Address - Street 1:3277 PHILLIPS RD
Practice Address - Street 2:
Practice Address - City:MARATHON
Practice Address - State:NY
Practice Address - Zip Code:13803-2139
Practice Address - Country:US
Practice Address - Phone:607-849-3545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239691-1164W00000X
NY649508-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse